Generating value is one of the most misunderstood tools of innovation. But it’s also one of the most important.

After all, value is what causes people to want to trade with you. Value is what makes someone decide to take out her wallet and hand you her money, because she’s going to get something she wants–something in which she finds compelling value.

Value isn’t fixed or tangible; it rests in perceived benefit. In other words, value is in the mind of the beholder. This is a key point. Innovators work hard to understand exactly what value means to their customers so they can generate and provide it. Value is an emergent property of supplier and consumer; it cannot take place with only one or the other.

So how exactly do you generate value? A focus on continuous, iterative improvement is not enough. I have identified three different ways to springboard innovations that generate value, which I describe in my book, Getting Innovation Right.

You can create new value; you can create more value; or you can create better value. New value is the most difficult strategy. The second strategy, creating more value, is much easier because you’re working with something you already have. The third strategy, creating better value, is also easier because again, it’s an extension of what you are currently doing.

1. New Value
Although some organizations do it very effectively, creating new value is the most challenging. To create new value requires breaking into a whole new sector.

Here’s an example: an association focused on increasing its membership. Rather than go after incremental gains in its target industry, it could create new value–and recruit new members–by adding a member category for vendors who sell to its industry. New value emerges from the need of members to find suppliers and the need of vendors to access a target market.

2. More Value
You can generate more value by applying one of three strategies: You can keep the purchase price the same and deliver more with every purchase; you can lower the purchase price and deliver the same quantity of value; or you can do both. Since value is in the mind of the beholder, any of these adjustments shifts that perception in the buyer’s favor. Whenever you can lower the investment and deliver more value, you should. Apple used this strategy when they released their second iPhone at a lower price than their first. That’s an example of creating more value.

3. Better Value
Like more value, better value relies on expanding an existing value. But instead of increasing the quantity, you increase the quality. Specifically, you can create better value with a change in impact, intensity, or application.

Creating better value with impact simply means delivering a more powerful punch behind the value that you currently have. To create better value through impact, change the consequence, the effect, the influence of a benefit your offering delivers.

For example, let’s say that an organization wants to leverage the asset of its quarterly journal. Its strategic response is to take that static printed periodical and turn it into an online forum, where customers are invited to be part of the conversation. The communication vehicle changes from a one-way channel to a multi-voice dialogue. That’s called increasing impact.

Now let’s look at increasing intensity. Intensity means that a benefit the product or service delivers actually does so with more strength, power, or potency. Let’s say that you provide an apartment-cleaning service, and you promised your customers that every apartment that you clean will meet federal and state standards. What if you suddenly promised customers that not only would their units meet federal and state standards, but also exceed the standards of local consumer groups? Now you’re going above and beyond what the law requires, to deliver what consumers actually want. That’s increasing the amount of intensity that your value provides.

Now let’s look at application. This means of providing better value applies the same benefits to a wider variety of uses. Look no further than your local college for an example. As online education has brought higher education within reach of many more people, colleges and universities are porting their classroom instruction over to online learning platforms. Now anyone interested in learning anything has access–not just the traditional student pursuing a specific degree. The benefit once available only to a few is now available worldwide–better value, available for a wider variety of uses.

Tradition may tell you that value represents the worth of goods or services as determined by the market, but that doesn’t recognize the most fundamental quality of value–that it is subjective, and can change according to circumstance. It’s your job as an innovation leader to identify what drives your customers, and to create offerings around those drivers. Bake in new, more, or better value–or combine these strategies to generate a curve of offerings, at various investment levels and delivering a variety of value propositions.

Pay attention to exactly what customers find compelling. Deliver that compelling offering by finding more, better, or new value, emergent in the coming together of buyer and seller.

“Power is not only what you have, but what the enemy thinks you have.”

“Never go outside the expertise of your people.”

“Whenever possible, go outside the expertise of the enemy.”

“Make the enemy live up to its own book of rules.”

“Ridicule is man’s most potent weapon.”

“A good tactic is one your people enjoy.”

“A tactic that drags on too long becomes a drag.”

“Keep the pressure on. Never let up.”

“The threat is usually more terrifying than the thing itself.”

“The major premise for tactics is the development of operations that will maintain a constant pressure upon the opposition.”

“If you push a negative hard enough, it will push through and become a positive.”

“The price of a successful attack is a constructive alternative.”

“Pick the target, freeze it, personalize it, and polarize it.”

Saul Alinsky was a 1960s activist who used non-violent action to make change. He made clever use of humour to disarm and out manoeuvre.

After organizing FIGHT (an acronym for Freedom, Independence [subsequently Integration], God, Honor, Today) Saul Alinsky once threatened to stage a “fart in” to disrupt the sensibilities of the city’s establishment at a Rochester Philharmonic Orchestra concert.

FIGHT members were to consume large quantities of baked beans after which, according to author Nicholas von Hoffman “FIGHT’s increasingly gaseous music-loving members would hide themselves to the concert hall where they would sit expelling gaseous vapors with such noisy velocity as to compete with the woodwinds.“

Satisfied with the reaction to his threat, Alinsky would later threaten a “piss in” at Chicago’s O’Hare Airport.
Alinsky planned to arrange for large numbers of well dressed African Americans to occupy the urinals and toilets at O’Hare for as long as it took to bring the city to the bargaining table. According to Alinsky, once again the threat alone was sufficient to produce results.

This tactic fell under two of his rules (Rule #3: Wherever possible, go outside the experience of the enemy and Rule #4: Ridicule is man’s most potent weapon).

I love manuals, guidelines, manifestos and top-ten-tips. There’s something very reassuring about a bullet pointed recipe of staccato do’s and dont’s. Like a Haynes car manual, or anything ring-bound with diagrams, the simple list makes it all much less cloudy.

For the program of the 22nd International Conference on Health Promoting Hospitals and Health Services (HPH) in April 2014, the Scientific Committee decided to focus on organizational culture and health.

Is the role of the manager to make decisions, or to make sure that decisions get made? The answer, of course, is both — but many managers focus so much on the first role that they neglect the second. The reality, however, is that decision-making often is not a solo activity, but rather an orchestrated process by which the manager engages other people in reaching a conclusion. Doing this effectively not only improves the quality of the decision, but also ensures that everyone is more committed to its implementation.

There are many ways to facilitate this kind of engaged decision-making, but here are two examples:

Several years ago a new senior leader was brought in to lead a large financial services business that was in need of a turnaround. Making this happen required a series of weekly decisions and tradeoffs about deals, marketing alternatives, internal investments, and human capital that affected most of the senior management team. While it would have been easier and faster to simply weigh the pros and cons of each issue and then give directions, the senior leader realized that her managers understood the implications better than she did, and that if they didn’t fully support the decisions, the execution might be compromised. So everyone had to be engaged. The problem was that the managers all approached the problems differently and had trouble reaching consensus — so they kept pushing the decisions back to her instead of hashing them out amongst themselves. To shift this pattern, the senior leader started holding her weekly team meetings on Friday afternoons, telling the group that she was prepared to stay as long as necessary until they reached agreements. The first few meetings stretched into the night, but eventually the team learned how to make decisions together — and how to get home for the weekend.

In another example, the division president of a manufacturing firm took an alternative approach to the same dilemma. Because the business was highly functionalized, senior managers realized that decisions in one area affected the others, so they escalated almost everything up to the president. While this made sense on paper, in practice the president became a bottleneck in the decision process, and everyone became frustrated with how long it took to get things done. To break this logjam, the president began to push back on each decision that was brought to him by asking a series of boilerplate questions such as, “How will this affect our customers?”; “Who else needs to be involved in this decision?”; and “What’s stopping you from working with your colleagues to figure out the right thing to do?” Eventually, through this repeated process of Socratic dialogue, the team members began to work through the issues with each other first, and brought far fewer decisions up to the president.

Every manager needs to make sure that decisions are made and implemented, whether it’s for an entire company or a small team. And while it may seem easier to just make the decisions yourself, in many cases this won’t lead to the best outcome — nor will it increase your team’s capability to make future decisions. The alternative, however, is not to shy away from decisions, but rather to create an orchestrated process by which the right people are engaged, including yourself.

Since 1973, when Jack Wennberg published his first paper describing geographic variations in health care, researchers have argued about both the magnitude and the causes of variation. The argument gained greater policy relevance as U.S. health care spending reached 18 percent of GDP and as evidence mounted, largely from researchers at Dartmouth, that higher spending regions were failing to achieve better outcomes. The possibility of substantial savings not only helped to motivate reform but also raised the stakes in what had been largely an academic argument. Some began to raise questions about the Dartmouth research.

Today, the prestigious Institute of Medicine released a committee report, led by Harvard’s Professor Joseph Newhouse and Provost Alan Garber, that weighs in on these issues.

The report, called for by the Affordable Care Act and entitled “Variation in Health Care Spending: Target Decision Making, Not Geography,” deserves a careful read. The committee of 19 distinguished academics and policy experts spent several years documenting the causes and consequences of regional variations and developing solid policy recommendations on what to do about them. (Disclosure: We helped write a background study for the committee).

But for those trying to make health care better and more affordable, whether in Washington or in communities around the country, there are a few areas where the headlines are likely to gloss over important details in the report.

And we believe that the Committee risks throwing out the baby with the bathwater by appearing, through its choice of title, to turn its back on regional initiatives to improve both health and health care.

What the committee found

The report confirmed three core findings of Dartmouth’s research.

First, geographic variations in spending are substantial, pervasive and persistent over time — the variations are not just random noise. Second, adjusting for individuals’ age, sex, income, race, and health status attenuates these variations, but there’s still plenty that remain. Third, there is little or no correlation between spending and health care quality. The report also effectively identifies the puzzling empirical patterns that don’t fit conveniently into the Dartmouth framework, such as a lack of association between spending in commercial insurance and Medicare populations.
The committee also confirmed earlier work by Harvard investigators showing that, for the commercially insured population, variations in the prices paid by private health plans explain most of the variations in private insurance spending. The committee deserves considerable credit for deepening our understanding of this irrational world of pricing commercial health care services. Yet as the report finds, even in the commercially insured population, there are substantial differences in utilization rates across regions. We would therefore argue that for commercial populations both price and utilization deserve attention, especially because in many regions, avoidable utilization may be easier to address than price.

It is Medicare spending growth, however, that represents arguably the greatest risk to the financial health of the U.S Treasury, and in Medicare, variations are almost entirely the consequence of utilization of services, not prices. The report finds that the single largest component of the variation in Medicare spending across regions that remains after risk and price adjustment is due to post-acute care (including skilled nursing facility services, home health care, hospice, inpatient rehabilitation and long term acute care). These services have also been a major source of growth.

But this focus on post-acute rather than acute hospital and physician services misses the key point that dysfunctional regional health systems are characterized both by hospitals providing fragmented and expensive care and by a large and thriving post-acute care sector ready and eager to absorb the discharged patients. For example, Joan Teno and colleagues at Brown University have established the strong association of inpatient treatments with no medical benefit, such as feeding tubes for people with advanced dementia, with high rates of regional resource use.

Which brings us to…..

The IOM committee’s policy recommendations: Where they hit the mark …

The committee makes five policy recommendations — and we agree with all of them. First, they call for making more and better data available, on both Medicare and commercial populations. Second, they recommend that CMS continue to test new payment models that encourage clinical and financial integration. Third, they call for timely and iterative evaluation of current and new payment reforms so that improvements can be made to the models. Fourth, they call on Congress to grant CMS the flexibility to accelerate the transition to value-based payment models as successful approaches emerge.

The fifth recommendation focuses on whether Congress should adopt a geographically based payment adjustment. When the committee was first mandated by Congress in the midst of health care reform in 2010, congressional members from regions with lower costs espoused a “Value Index” in which Medicare would reward low-spending regions with higher reimbursements, at the expense of high-spending regions. The committee concluded that payment mechanisms should not be tied to region, but instead targeted to individual providers, rightly criticizing the Value Index approach as not providing institutions and systems with the right incentives to reduce costs and improve quality.

… and where they fall short: Geography does matter

We believe, however, that the committee, by subtitling the report “Target Decision-makers, Not Geography,” will confuse the media and casual readers (for example, those who don’t make it to page 3-3 in the full report) by appearing to cast doubt on the promise of geographic and regional efforts to improve the quality and efficiency of U.S. health care.

As the late Nobel-Prize winning economist Elinor Ostrom has emphasized, successful management ofcomplex social problems can best be achieved through sustained collaboration among diverse stakeholders, often across traditional political boundaries. She demonstrated that cooperative agreements are often the most effective approach to solving the kinds of problems we face in health care. Among these are the natural instincts of physicians and hospitals within local health care systems to protect their financial health by expanding capacity and defending market share, whether by opening new cardiac centers when the one at the nearby hospital is perfectly adequate, or by buying proton accelerators that will be used to treat conditions where they offer no demonstrated benefit.

The rationale for a geographic focus on health care reform is strong: the factors that determine population health are largely local, rooted in the environmental, social, economic, and behavioral determinants of health. Many of the factors that influence health care quality and costs are also local, including local supply, pricing behavior, and the relative emphasis of providers on profit. For example, in the widely cited New Yorkerarticle by Atul Gawande, Medicare utilization in McAllen was found to be nearly twice as high as that in another Texas border town, El Paso, despite the existence of multiple hospitals in both McAllen and El Paso, nearly identical Medicare prices, and common Texas malpractice laws.

Many regional multi-stakeholder initiatives have been established. Although most began with a focus on quality, many are beginning to act more broadly to both improve health and lower costs: Three examples include Pueblo Colorado (Regional Triple Aim), Akron, OH (Accountable Care Community), and the Atlanta Regional Collaborative for Health Improvement (focused on driving provider transitions to global payment, capturing savings, and reinvesting in strategic population health initiatives).

While the IOM Committee is exactly right to call for improved financial incentives for health care providers, we should also remember that both health and health care are local. Geography matters.

Elliot Fisher, MD, MPH and Jonathan Skinner, PhD are professors at Darmouth’s Geisel School of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice. Fisher is a principal investigators, and Skinner is a senior scholar of The Dartmouth Atlas Project.

Have you ever felt like making a comparison between entrepreneurship and extreme competitive sports? If so, you’re not the first. My team member Adam Torkildson drew my attention this week to someone he met through his interest in extreme fitness–Mark DeLisle, a former Navy SEAL and current fitness instructor at National Institute of Health and Fitness.

It seems fitting that Navy SEAL training would be ideal preparation for business ownership. Everything begins with commitment and attitude for the Navy SEAL Teams. The idea of failure is not an option. In order to fathom this concept they are trained to eliminate the words – “I can’t.” They know their capacity to perform at high levels drops substantially the minute they let doubt enter their minds.

If you have the desire to be a corporate warrior, DeLisle claims, you need to let go of any normal parameters that can restrain an average corporate executive’s way of thinking. His favorite phrase is this: “The only limitations we face in life are the ones we place on ourselves.”

How are Navy SEALS like successful entrepreneurs? It turns out there are plenty of ways. For example, to be successful, you must fully commit and must fully believe in yourself. Ask yourself “What is the objective?” Then visualize it, believe it and achieve it. No excuses allowed.

Motivation comes from within, Mark maintains, and unless you internalize your motivation, you are done. He and other Navy SEALs refer to this internalization as “gut check.” Do not let anyone tell you that you cannot achieve something, he says. The time for gut check is now. How could Navy SEAL-style thinking and training prepare you for your own business success? Here are a few additional thoughts:

Perceived Personal Limitations

The human body has a survival mechanism and it does not like to leave its comfort zone or be surprised. In order to guard against extremes of discomfort, fear and surprise, the body may place doubt as a roadblock to success.

The body will do whatever it takes to keep you in its normal rut. Doubt will come in many forms, ranging from mental games, to limiting physical capacity to prohibiting emotional motivation. Mark has observed that an otherwise perfect specimen of a SEAL candidate will sometimes quit just 30 minutes or even 10 minutes short of an activity’s termination point (or time limit) because the candidate has lost focus on the goal.

The candidate fell short because of an unwillingness to sacrifice the energy and an inability to find the will to go on. He or she was not sure how much more their body or mind could take. They get ten minutes from greatness and from achieving a goal that would stand for the rest of their lives, and they stop.

So if you’re preparing to succeed in business, you must eliminate perceived personal limitations on the spot. Any doubt must be removed from your mind in an instant. Do not let the words “I can’t” enter your vocabulary again.

Make It Happen

Now that you are willing to break down the walls and start from scratch, let’s look at the making of a corporate warrior. From the start of SEAL training to the end, these candidates were empowered to achieve those things that others say are impossible.

Many briefings are closed with the phrase: “Make it Happen.” Instead of saying, ‘I want you to figure out how to do this’ or ‘Do you feel you are ready?’ the SEALs were told, “Make it happen.”

The commanding officer, the boss, does not care how participants accomplish the goal or if they are ready. His confidence in them does not allow him to doubt that a task would be done. It is as simple as “Make it happen.”

To empower yourself, or even better, to empower your team, verbalize those three words every day. It shows that you have no doubt you or your team can get their accomplishment done. It shows you have the confidence that you and the team will get all the way to your goal. Force your team members to get out of their comfort zones, to be creative, and find new ways to accomplish their tasks.

Visualize walking into a meeting, giving your team your objectives and telling them what needs to happen. You simply say, “Make it happen” and walk out. They may be puzzled at first but will soon switch into “survival mode” and figure out a way to make it happen.

You have just empowered your team to become an unstoppable force. You have shown a tremendous amount of confidence in them and what they can accomplish if they work together as a team. This will give you a chance to see hard chargers rise to the top.

Empowering others shows trust and confidence that they will not want to fall short of, and will never forget. You will be amazed at the level of creativity individuals and groups can achieve when they go into survival mode and must rely on themselves. You might be even surprised at the concepts or ideas that come out of your team when they are asked to find the path to reach their goals.

A SEAL’s true potential is never achieved unless they are broken down and forced to rely on instinct and personal strength, Mark maintains. True warriors learn how to do this for themselves first, and then for the team.

A phrase the SEALS use often is “You are only as strong as your weakest link.” Don’t be afraid to take the weakest person in your team and turn them into a strength. Maximize the strengths of those around you while strengthening those assets of someone’s weaknesses. A sign of a true corporate warrior is not being afraid to make those around you better than they are.

Leadership By Example and Sacrifice

What sets SEAL training apart from other military branches is the assertion that SEAL training is the toughest in the world. In addition, there is no special treatment or exemption for officers or executives. SEALs leaders go through the exact training as enlistees and they get dirty in the trenches alongside their teams.

According to Mark, “there would be nothing worse than being lead by a ‘cake eater’ that couldn’t lead by example.” In the corporate world it happens time and time again. Managers and executives become disconnected, and thus discounted or disrespected by their teams.

During Hell Week – the final training week, which must be without sleep, by the third day the SEALs are tired, cold and miserable. The platoon officer is just as cold and miserable as his team. He picks the team up off the ground and looks at them as he says, “We are not going to let them beat us!”

The incredible respect for each other within a SEAL Team comes down to having sacrificed through the toughest of times together. Trainees know that no matter how tough it gets, the team members right next to them will all have their back.

Do you have your team’s back? Are you willing to get dirty in the trenches along with them? Are you willing to lead by example?

End Objective

If a team feels disrespected, or their leadership is not willing to get into the trenches or not allowed to get out of their comfort zones without fear of consequences, they are not being utilized to the best of their ability.

How would you feel as a hard charger if you were allowed to drive hard, be creative, and make things happen knowing that those above were giving you their all-out support? It would be amazing.

Now apply that same principles to yourself as a leader. Eliminate the parameters that are restricting your progress and do a gut check. Find the internal motivation necessary to make things happen to ensure your motivation will not be short lived. Do not limit yourself to what you currently think you are capable of doing, and set newer and more powerful goals that will take you and your team to the next level you seek. “The only easy day was yesterday,” as Mark would say. Hooyah!

Additional reporting for this article was provided by Adam Torkildson, Snapp Conner PR. We have no business relationship with Mark DeLisle or his company. Adam was recently introduced to DeLisle by his personal and business mentor Ken Krogue, Forbes Contributor and President of InsideSales.

As we grapple with provider shortages, the surge in chronic illness and the quality to price (QPR as they say in the wine business) challenge in US healthcare delivery, it’s hard to imagine a future that does not include some sort of guideline or algorithm-driven care. As providers take on more financial risk, one common strategy involves team-based care, and the attendant increase in decision-making and care delivery by non-physician clinicians. If the je ne sais quoi feature of a quintessentially great doctor is clinical judgment and instinct, one of the challenges of this transition to team-based care is how to harness that trait and use it efficiently.

Care decisions that are unassailable at a population level (e.g., women should have regular, routine PAP smears or smoking is bad for your health) or are algorithmic in nature (e.g., titration of treatment for uncomplicated hypertension or therapy for mild to moderate teenage acne) can all be effectively reduced to guidelines. This, in turn, allows a physician to delegate certain therapeutic decisions to non-physician providers while maintaining a high degree of care quality. It is also thought that this type of uniformity of care delivery will improve the QPR too, by decreasing variability.

How do we come up with guidelines? Typically they are based on large-scale, randomized, controlled clinical studies. As is nicely articulated in a recent JAMA opinion piece by Drs. Jeffrey Goldberg and Alfred Buxton (JAMA, June 26, 2013—Vol 309, No. 24, pg 2559), guidelines are formulated based on the inclusion criteria for these trials. This process gives us comfort that guidelines are based on rigorous science — and that is a good thing. The challenge arises when we realize that individuals do not reflect populations exactly. Clinical research is much more complex than wet lab work because people are complex and indeed unique. Every clinician has had the experience of prescribing a therapy to a patient who fit guideline criteria exactly and having the opposite outcome of what the guideline predicts.

Goldberg and Buxton point out the collision of this guideline-based care delivery model with the burgeoning area of personalized medicine. I was immediately drawn to their definition of personalized medicine: “The tailoring of medical treatment to the individual characteristics of each patient. It does not literally mean the creation of drugs or medical devices that are unique to a patient, but rather the ability to classify individuals into subpopulations that differ in their susceptibility to a particular disease or their response to a specific treatment.” I always felt like there was too much emphasis on the genetic components of personalized medicine.

Our vision at the Center for Connected Health (which is backed up by our experience to date) is that we will get far richer and complex data from multiple phenotypic inputs such as physiologic monitoring data, mood and motivation-related data than is represented by genomic data. The genome is an incredibly important anchor for devising a personalized medicine profile, but the profile will change over an individual’s lifetime according to these phenotypic inputs.

We’ve done some preliminary work on this and found that indeed we can map individuals phenotypic data over time as they go through an intervention designed, for example, to improve activity level. During a six month period of tracking activity and motivation, we have seen dynamic changes in these two variables. Think about it over a lifetime.

The collision with guidelines is multifactorial. We are all individuals and none of us are completely representative of the composite patient who is defined by the inclusion criteria for the clinical trial that lead to the guideline. Thus, some of us are bound to be poor candidates for the prescribed intervention (I hate to mention it, but we’ve all seen examples of Uncle Harry who smoked two packs per day, lived into his 90s and died of causes unrelated to smoking). If that wasn’t enough, there is the fact that we change over time and though we might fit a guideline today, we may not in a year.

Really, when you think about it, ‘clinical judgment and instinct’ is the 20th century (and earlier) embodiment of personalized medicine. Those of us who are clinicians can all point to experiences where we’ve said, “I can’t tell you why, but I really think we should do it this way” (this way being contrary to conventional wisdom) and it has generated a positive outcome. Of course we also have experiences where the outcome is not good or where we make mistakes that could have been prevented by adherence to guidelines.

How to make sense of this complex and contradictory situation? Here’s my take:

Personalized medicine, however you define it, is still in the very early stages. We have decades to go, probably on both the genetic and phenotypic fronts, before we can comfortably replace guidelines.

We should welcome the sharing of decision-making across the care team and maximize the use of non-physician clinicians. Guidelines give us the state-of-the-art way to do this.

The best form of personalized medicine today is still clinician instinct and judgment. This does not mean deferring all clinical decisions to the most senior or most highly trained person on the team. The care delivery culture can be modified to maximize appropriate personalization of care while adhering appropriately to guidelines. This requires an open culture where inquiry is encouraged. Each care team member must be comfortable with what he or she doesn’t know, with spotting exceptions to norms and engaging other team members in a learning dialogue around these exceptions.

This should enable guidelines to be appropriately applied while surfacing exceptions for discussion. In the meantime, we and others will be working as fast as we can to create the framework for personalized medicine from both the genetic and phenotypic perspective.

It’s been about a year now since we lost several of our leaders due to random acts of misaligned values. Thinking back, I remember waking up one morning in the midst of all the difficult conversations and posting the following on Twitter:

“Contrary to popular opinion Values Based Leadership cultures are very fierce, especially when the values are more than just words on the wall.”

In the days that followed, there was nothing flowery about the state of the enterprise as the difficult conversations continued and communications became paramount. And each year that goes by in our values journey we realize more and more that Values Based Leadership cultures are anything but “hugs and roses” as many would define them.

As a point of clarity, it’s not the rare events that end in the loss of an associate that best represent our culture. It is instead the day-to-day “fierce,” feedback rich, developmental conversations that define us at our best. Especially when these actions and behaviors are underpinned by authentic relationships and balanced with a higher frequency of recognition for a job well done. And while none of us wake up in the morning hoping for a day full of fierce conversations, in an organization that aspires to have a feedback rich culture, few go by where an opportunity does not present itself.

For me, this past Friday was one of those days. I was scheduled for a routine catch-up with one of our leaders and just prior to the meeting evidence was surfacing that we may have, in our terms, the need for a “values clean up on aisle 7.” And sure enough, we did in fact have a bit of a mess on our hands. The good news is after asking the leader just a few questions, the issue became obvious and he quickly accepted responsibility for the situation. The better news is before I even got back to the office, a call was made and an apology offered. The best news is the young associate on the receiving end of the apology was beyond inspired by the call she received. A point to note is that the leader is actually one of our officers. So what went right?

We are very intentional about cultivating a feedback rich culture that asks us to be thoughtful when giving and gracious when receiving feedback.

One of our four core values is leadership, which includes a behavior that asks us to “initiate transparent and fierce conversations.”

We obsess about our relationships up and down the organization as a means of “soil prep” in the event a difficult conversation is necessary. It’s about trust and communication.

One of our core Values Based Leadership competencies is character strength, which includes an attribute of “taking action.”

We recognize and reward actions and behaviors that align with our company values and Values Based Leadership competencies.

At Luck Companies we do believe Values Based Leadership cultures are extraordinarily fierce. As such, we have built a system around our company values and Values Based Leadership competencies that ensure our associates are up for the challenge. And what about you? Is your organization fierce, feedback rich, and developmental to the extent that is required to navigate the current (and foreseeable future) “fierce” business climate? Or are you settling for flowery, where realities are not interrogated and much needed conversations are left unsaid?

In today’s health care environment, we are all driven to see more patients in less time and do more with less support. Obviously most of this is financially motivated — the delivery of medical care had unfortunately become more of a business than an art. As more physician groups are now owned by hospital systems, the “bean counters” and administrators are now crafting the rules of engagement. Physicians no longer have the luxury of time for a leisurely patient visit. No longer do we have the time to routinely ask about the grandkids and the most recent trip that our favorite patients have taken in their retirement. Ultimately, it is the patient who suffers.

Those who are ill and those who love them often need more than pills, blood tests, IV fluids and heart monitors — they need support and genuine caring. These patients and families need a doctor or other health care provider to sit on the edge of the bed and unhurriedly listen to their concerns — to simply chat for a bit. Unfortunately, this is no longer the norm. Luckily, we have dedicated caregivers on the front lines in our hospitals who can often fill the gap: nurses.

I was moved last week as I read a wonderful article in the New York Times by Sarah Horstmann. In the essay, Ms. Horstmann (a practicing registered nurse) describes her special connection to a few patients and their families on the orthopedic unit in which she works. She chronicles her struggle with remaining objective and professional in her role as nurse when she becomes emotionally invested in her patients. She paints a picture of an engaged and caring nurse who is able to put everything on the line for her patients. Her internal struggles with “crossing the line” in her care for the patient is one that we all as health care providers have faced at one time or another.

However, she handles her feelings and her patients with absolute grace. We can all learn a great deal from Ms. Horstmann. We should all strive to feel and care as deeply as she does. Our patients and the care we will provide them will certainly benefit greatly.

In medicine, it is the nurses that often lead the way for all of us. They spend the time required to get to know the patient — their fears, their thoughts about disease, their thoughts about their own mortality. Nurses understand family dynamics and can help in managing difficult family situations. Nurses make sure that above all, the patient comes first — no matter what the consequences.

The very best nurses that I have worked with over the years are advocates for those who are too scared or too debilitated to advocate for themselves. Many times early in my career, I did not pay attention or listen to the lessons that were all around me on the hospital wards. However, as I approach mid-career I am much more attune to these very same lessons that I may have missed earlier. There is much gained when we watch and listen to others who are caring for the same patient — maybe in a different role — but caring for our common patient nonetheless. I now realize that nurses have “shown me the way” many times and for that I am truly grateful.

Emotional investment and developing patient connections can improve care and assist patients and families with acceptance and with eventual grieving and loss. I believe developing bonds with patients is a wonderful expression of love for another human being and is completely acceptable in medicine — as long as we are able to remain objective when critical clinical decision making is required.

In medicine we strive to provide excellent care for all patients but every now and again there are special patients that we develop emotional bonds with. Just as in everyday life, there are certain people that you are able to connect with in a spiritual way — whether they are co-workers, colleagues, friends or significant others. We must stop and appreciate the way in which nurses provide care — we can learn a great deal from them and ultimately provide more “connected” care for our patients.

So, next time you are in the hospital, find a nurse. He or she will likely be haggard from running from room to room, and it is likely that they have not stopped to eat lunch. Thank them for caring for our patients. Thank them for showing us all how to provide better care for our patients. Then, stop in and say hello to your patient — sit on the edge of the bed and take time to simply just chat.

The latest State of the American Workplace report from Gallup tells us once again that only about 30% of Americans are engaged at work. The number of disengaged workers costs the U.S. $450 billion to $550 billion per year.

This engagement crisis is the same story we’ve been hearing for over a decade, yet most organizations still fail in their efforts to increase the commitment of their workers. Why?

Based on my own journey from bad boss to Best Place to Work award winner, and on my reviews of hundreds of case studies, these are the most common reasons executives’ employee engagement efforts fail:

1. They confuse engagement with happy.

Often engagement initiatives crater in the C-suite because senior executives don’t know what employee engagement is. They may confuse it with nice but “soft” efforts to make employees “happy.”

Engagement is the emotional commitment one feels to their organization, and to the organization’s goals. When engaged, employees give discretionary effort—the secret sauce to gains in productivity, sales and ultimately profits.

2. They don’t think engagement can be measured.

Even some notable business gurus were quoted recently as saying, “Don’t try to measure engagement or you’ll kill it.” Or you can’t measure engagement, but you know it when you see it.

To the contrary, HR consultancies from Gallup to Kenexa have found ways to measures proxies of engagement. Measurement is the first step in managing better outcomes.

3. They measure it but don’t share results.

Typically, when an engagement survey is completed, the results are scrutinized by the C-level executives and the HR professionals. Rarely are all the results shared throughout the company. Only when individual managers get their own team scores can transformation occur.

4. All the ideas for improvement come from the top.

Related to No. 3 above, senior execs often work as a council of wise men and women, brainstorming better benefits or new award programs for the whole company. The secret to engagement is that it comes from the relationships front line managers have with their direct reports. Only action planning at the individual team level will generate the ideas that will move the needle.

5. They think it’s about picnics and parties.

Unfortunately, top-down ideas typically include things like summer picnics, dress down Fridays and Employee of the Month awards. The true drivers of engagement are growth, recognition, trust andcommunication. While people might feel “happier” during the time of a party, only a true change in their daily and weekly work experience will make them feel emotionally connected to their organization.

The employee engagement crisis has gone on long enough. All organizations that strive for excellence should implement an annual measurement survey, share the results down to the front-line managers, and insist on team-level action planning to move the scores in the right direction.

Regardless of the specific approaches they took, the initiatives in all of these success stories centered on creating cultures of engaged, proactive employees through improved communication and specialized social media training.

The following are some key takeaways to help social executives on their social journeys.

1. The why matters.

Social employees are happy to do what is asked of them, as long as they understand the reason for the task. As Don Tapscott said in the afterword of Jacob Morgan’s The Collaborative Organization,

The baby boomers were satisfied with knowing what decision was made, but today’s young employees want to know why. They’re not insubordinate; they just recognize that understanding the reasons behind the decision can make the difference between success and failure in implementation.

This attitude is actually quite helpful to an organization. By understanding the why of a task, the social employee will be able to contextualize the task as part of a larger objective. As a result of this, the employee might even be able to adapt a more efficient process for the task—clearly making this a win-win for the company.

This process applies the spirit of Simon Sinek’s mantra: “People don’t buy what you do. They buy why you do it.” In this case, however, the customers are the company’s employees. They are the ones who need to be convinced in order to buy in to the process.

During the company’s social adoption process, Cisco developed the “WWHW Wheel” as a means of building employee buy-in for the planned changes. The wheel, which stood for what, why, how, when, indicated the different stage of buy-in company managers were as they discussed new initiatives.

Cisco executives knew where their managers were on the WWHW Wheel by the kinds of questions they were asking. For instance, if they were still asking basic questions about the change itself, those managers were still working to grasp what the change was. As soon as the managers began asking for the reasoning (the why) behind the change, then executives knew that those managers had moved to the why portion of the wheel. By monitoring where their employees were along the wheel, executives were able to tailor the pace of the conversation to the group, allowing them to build broad support for the planned changes by fostering a deeper understanding of those changes.

2. Walk the talk.

Executives must remember that social business means increased transparency and visibility. Social employees are far more likely to adapt target behaviors if they see the C-Suite leading the way to change. So, just as businesses work to build social employees, they must also build social executives. In just a few years, we fully expect to see social media competence as a prerequisite for executive-level jobs.

CEO Josh James at Domo embraced this challenge with gusto when he announced the #DomoSocial program out of the blue in May of 2012. This innovative program mandated employee adoption of social media over the course of several weeks.

The reasoning behind the program was that it was more beneficial for everyone to learn how to go social all at once. By undertaking the process as a group, employees would talk to each other about what they’d learned, supporting each other when inevitable flubs were made in the adoption process. James had a very visible role throughout, transparently modeling the behaviors and ideas that he wanted his employees to emulate, and regularly posting the program’s progress on his blog.

While in Domo’s case their CEO had perhaps a better grasp of social media’s benefits, with many other organizations the reverse is often true. In other words, a company’s employees usually have a better understanding of social media than their executives do. These employees are a valuable resource to executives working to build their social media skills.

For instance, many of the companies we spoke with also had some type of reverse mentoring program, in which employees would work directly with their superiors to model effective strategies and skills. Not only did this give executives an in-house resource to build their own knowledge base, it gave employees a chance to make a name for themselves among the senior ranks.

3. Ideas are a shared responsibility.

Social business has allowed for the design of dynamic new collaboration processes. Sharing ideas and information has never been easier. Greater access to information, resources, and tools within a company creates many internal crowdsourcing opportunities. The executives we spoke with were constantly astounded by the way individual talents would shine through and build off of each other through the process of group collaboration.

At IBM, this kind of open communication led directly to the development of the enterprise platform Connections by way of the company’s Technology Adoption Program (TAP). It also led to the development of the company’s social media policy. When it came time to formalize IBM’s relationship to social business, executives understood that many of their employees already had a nuanced understanding of social media engagement through their own online experiences.

Clearly, this knowledge was a tremendous resource to waste. To capitalize on this pocket of expertise, IBM set up a wiki and invited all its employees to contribute their thoughts on what the company’s social media policy should be. Eventually, a document emerged that IBM’s Ethan McCarty called the company’s Magna Carta. So successful were the company guidelines, in fact, that many other companies have asked IBM for permission to adopt that policy as their own.

It was apparent to us that strong executive leadership was essential to building a sustainable social employee culture. The social executive is a catalyst for a company, leading employees by example by modeling the company’s mission, vision and values.

Author: Cheryl BURGESS

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Bio: Cheryl Burgess, author of The Social Employee (McGraw-Hill, summer 2013) and CEO of Blue Focus Marketing, is an award-winning social branding marketer and speaker with expertise in B2B marketing. Burgess, who Hufﬁngton Post called a social media “Passionista,” appears regularly as an expert blogger for AT&T Business Solutions. Blue Focus Marketing won the 2012 Reader’s Choice Award for Best Social Media Marketing Blog. She is a member of the Wharton Advertising 2020 Contributor Community. She is also the winner of four Twitter Shorty Awards. In 2011, she cofounded the #Nifty50 Top Men & Women on Twitter Awards. Follow her on Twitter at @ckburgess @SocialEmployee and @BlueFocus.

Grace Huang, M.D., Director of Assessment at the Shapiro Institute and Assistant Professor of Medicine at Harvard Medical School

No topic is more timely or relevant to the current political climate than cost-effective care. We at the Shapiro Institute for Education and Research prefer to frame the concept as “value-added care,” which incorporates patient-centered outcomes, including potential harm and discomfort from diagnostic testing. In the face of data that demonstrate wasteful testing and treatments contribute significantly to our rising health care costs, practicing physicians are under pressure to be part of the solution.

The lay public clearly is attuned to this crisis as expressed in the popular press and media reports and is demanding to know why physicians are not taught to consider the value and cost of the tests and treatments they recommend. Changing physician behavior, however, requires more than knowledge-based instruction; rather, we must identify and address the cultural factors that contribute both to patients’ demands and expectations and to physicians’ actions.

Our historical model for training physicians has neglected to incorporate contemporary principles of resource utilization, harm from diagnostics, and cost considerations into medical education curricula. The medical, physical, and emotional consequences of false-positive testing are not real to medical students. Even in the hospital environment, where trainees become increasingly aware of delivery issues—such as readmission rates, observation status, and case management—they still operate under assumptions that tests and services are fully reimbursed and that hospitals are profitable. Consequently, when residents enter the workforce, they are unprepared for the economic realities of our health care system and typically lack the tools necessary to navigate an optimal patientcentered, cost-conscious approach to the evaluation and management of their patients.

Topics such as epidemiology, evidence-based medicine, and diagnostic reasoning represent the cornerstones of the preclerkship curriculum for medical students. But the hidden curriculum and test-ordering practices of attending physicians (who often drive the ordering decisions of trainees) hinder the effective application of these theoretical principles during actual clinical experiences. Most faculty members are neither trained in high value care nor able to identify “best teaching practices.” Academic doctors, particularly those practicing in tertiary medical centers, strive to teach their students and residents the breadth and depth of medicine. The longer and more intricate the differential diagnosis, the better, and supervising physicians often are loath to stifle the curiosity of their trainees.

Patient expectations fuel excessive testing. The fear of malpractice litigation may incentivize health care professionals to pursue diagnostic certainty even at the cost, both financial and human, of multiple tests and procedures. Physicians may assume that patients will seek alternate care if their doctor is reluctant to pursue whatever test the patient thinks is necessary, regardless of the cost. Physicians also may opt for the perceived “easy way out” by giving the patient what he or she wants, rather than entering into a thoughtful, but timeconsuming and potentially difficult, conversation about the reasons for avoiding that diagnostic pathway.

There have been positive steps to reduce waste and contain costs. Campaigns such as Choosing Wisely at the American Board of Internal Medicine have spurred professional societies to highlight unnecessary tests for their specific specialties, while the High-Value Care Curriculum at the American College of Physicians (ACP) provides the knowledge elements and tools to deliver content. But these initiatives, although incredibly valuable starting points for these discussions, may not sufficiently address our medical culture, which demands diagnostic certainty. One key question remains: If we want to influence the actions of future physicians, how do we optimally teach these principles to our current trainees?

In this context, the Shapiro Institute convened an invitational Millennium Conference on Teaching Value-Added Care, co-sponsored by the AAMC and in partnership with the ACP. This spring, teams from six medical schools—Drexel University College of Medicine, Dalhousie University Faculty of Medicine, Geisel School of Medicine at Dartmouth, Case Western Reserve University School of Medicine, Penn State College of Medicine, and Mayo Medical School—joined the Harvard/Shapiro team to consider challenges of the learning environment, propose best instructional practices, and engage in a structured dialogue to build consensus on how to teach value-added care across the medical education continuum.

We will detail our findings in future proceedings. A preliminary summary includes the following highlights.

Value is not strictly about cost; it comes from the patient’s perspective. As such, we must teach and serve as models for the behaviors that elicit patient concerns and preferences about the many nonmedical factors that influence their perceptions of health care. To explain why a particular study highlighted in the media does not apply to an individual patient requires not only knowledge of study design and biostatistics, but also the ability to translate that information to a patient who may not fully understand the study results. Discussing the complications of testing, particularly the consequences of false-positive findings, is challenging and requires a range of communication skills.

Teaching value does not necessarily require significant amounts of extra time.When a test of questionable value is ordered, ask the student or trainee, “How will the results affect what we will do with this patient?” At the end of patient rounds, consider adding questions that foster appropriate test ordering, such as, “Is there anything we ordered today that the patient does not need?” During the traditional morbidity and mortality conferences, add a discussion of hospital costs incurred.

Tackle the hidden culture head-on. The clinical learning environment is typified by routine daily labs, unnecessary diagnostic evaluations, and repeat imaging. Foster a reward system that values cost-effective care by discouraging extensive differential diagnoses that include diseases that are obscure and have a low probability of producing the patient’s clinical picture. Train a core faculty with demonstrated expertise in teaching these topics. Incorporate practice audits of ordering behavior into the teaching competencies of faculty.

The deliberations and recommendations of the committed faculty who attended the Millennium Conference 2013 are only the beginning of our efforts to enhance the teaching of value-added care. We hope our findings will stimulate additional initiatives across the United States and Canada.